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Bariatric surgery, compared to medical treatment, reduces morbidity at all ages but does not reduce mortality in patients aged < 43 years, especially if diabetes mellitus is present: a post hoc analysis of two retrospective cohort studies

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Abstract

Background and aims

Bariatric surgery (BS) reduces long-term mortality in comparison with medical treatment of obesity. Some studies indicate that this effect is significant for patients above mean age in different cohorts, but not for younger patients. These findings raise the question whether morbid obese patients should undergo BS as soon as possible, or whether patients might undergo surgery later in their life.

Methods

We performed a post hoc analysis of two studies; we evaluated surgery-related long-term mortality in: (1) the whole cohort [857 surgery patients (163 diabetes) vs. 2086 controls (512 diabetes)]; (2) patients above mean age [> 43 years, 427 surgery patients (133 diabetes) vs. 1054 controls (392 diabetes)]; (3) patients below mean age [≤ 43 years, 432 surgery patients (30 diabetes) vs. 1032 controls (120 diabetes]. Then, we analyzed age-related long-term mortality in the whole cohort, as well as in surgery patients and in controls. Finally, we analyzed incident diseases (diabetes, cardiovascular disease, and cancer) as a function of surgery versus no-surgery and of mean age.

Results

Surgery patients, compared with controls receiving standard medical/dietary treatment, had reduced mortality in the whole cohort (HR = 0.45, 95% CI 0.33–0.62, p = 0.001) and in the study group aged > 43 years (HR = 0.39, 95% CI 0.28–0.56, p = 0.001), but not in the study group aged ≤ 43 years (HR = 0.87, 95% CI 0.42–1.80, p = 0.711). Reduced mortality was observed in non-diabetic and diabetic patients aged > 43 years (HR = 0.37, 95% CI 0.23–0.62, p = 0.001 and HR = 0.45, 95% CI 0.27–0.74, p = 0.002, respectively) who underwent bariatric surgery. In contrast, in patients aged ≤ 43 years, no significant protective effect of bariatric surgery appeared in non-diabetic patients (HR = 0.64, 95% CI 0.24–1.71, p = 0.371), and mortality increased, almost significantly, in diabetic patients aged < 43 years (HR = 2.87, 95% CI 0.96–8.56, p = 0.058), and even more in diabetic patients aged 33–43 years; HR = 4.99, 95% CI 1.18–21.09, p = 0.029). As expected, age-related mortality was increased in the whole cohort (HR = 7.23, 95% CI 5.14–10.17, p = 0.001), in non-diabetic and diabetic controls (HR = 8.55, 95% CI 5.77–12.68, p = 0.001, and HR = 3.76, 95% CI 1.97–7.18, p = 0.001, respectively). The effect of aging was slightly reduced in surgery patients (HR = 3.76, 95% CI 1.87–7.58, p = 0.001), while it was not significant in diabetic surgery patients (HR = 0.70, 95% CI 0.26–1.90, p = 0.88), further emphasizing that diabetes per se has a strong negative effect on survival, also with concomitant bariatric surgery. In a supplementary analysis, HRs did not change when surgery and control parents were matched for the presence of diabetes. Incident diseases (cardiovascular, diabetes, and cancer) were less frequent in surgery than in control patients, irrespective of age.

Conclusion

Bariatric surgery reduces long-term mortality in comparison with medical treatment when performed in patients aged > 43 years, but not in younger patients, where it is neutral or could even increase mortality; reduction in morbidity occurs at any age.

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Abbreviations

BMI:

Body mass index

BG:

Blood glucose

HbA1c:

Glycated hemoglobin

e-GFR:

Estimated glomerular filtration rate (ml/min/1.73 m2)

AST:

Aspartate transaminase

ALT:

Alanine transaminase

CHD:

Coronary heart disease

LAGB:

Laparoscopic gastric banding

RYGB:

Gastric bypass

BPD:

Biliopancreatic diversion

BIBP:

Biliointestinal bypass

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Funding

Università degli Studi di Milano, Milano; Ospedale San Paolo, Milano; Istituto Multimedica, Milano; Harvard Medical School, Boston Children’s Hospital; Grant “Ricerca Corrente” to Istituto Multimedica from Ministero della Salute (Ministry of Health), Italy.

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Authors and Affiliations

  1. Dipartimento di Scienze della Salute, Università degli Studi di Milano, ASST Santi Paolo e Carlo, Via Antonio di Rudinì 8, 20142, Milan, Italy

    Antonio E. Pontiroli & Franco Folli

  2. IRCCS MultiMedica, Milan, Italy

    Valerio Ceriani & Elena Tagliabue

  3. ASST Santi Paolo e Carlo, Milan, Italy

    Ahmed S. Zakaria, Annamaria Veronelli & Franco Folli

  4. Harvard Medical School, Boston Children’s Hospital, Boston, MA, USA

    Ivan Zanoni

  5. Università degli Studi di Milano Bicocca, Milan, Italy

    Ivan Zanoni

Authors
  1. Antonio E. Pontiroli
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  2. Valerio Ceriani
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  3. Elena Tagliabue
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  4. Ahmed S. Zakaria
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  5. Annamaria Veronelli
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  6. Franco Folli
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  7. Ivan Zanoni
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Contributions

AEP, VC, and IZ planned the research, contributed to discussion, wrote the manuscript; ASZ and AMV searched data, prepared the database, contributed to analysis, and contributed to discussion; ET performed statistical analysis and contributed to discussion; FF searched data, contributed to discussion, and edited the manuscript. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Antonio E. Pontiroli or Franco Folli.

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The authors declare that they have no conflict of interest.

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This study was funded by Università degli Studi di Milano, Milano; Ospedale San Paolo, Milano; Istituto MultiMedica, Milano; Harvard Medical School, Boston Children’s Hospital; the Grant “Ricerca Corrente” was issued to Istituto MultiMedica from Ministero della Salute (Ministry of Health), Italy.

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Pontiroli, A.E., Ceriani, V., Tagliabue, E. et al. Bariatric surgery, compared to medical treatment, reduces morbidity at all ages but does not reduce mortality in patients aged < 43 years, especially if diabetes mellitus is present: a post hoc analysis of two retrospective cohort studies. Acta Diabetol 57, 323–333 (2020). https://doi.org/10.1007/s00592-019-01433-3

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  • DOI: https://doi.org/10.1007/s00592-019-01433-3

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